Birthing policy review delivers confusion

HAGERSTOWN - When April Canby of Hedgesville, W.Va., had her first baby in 1999, he had a medical condition that required her to have a Caesarean section.

But with two subsequent pregnancies, she opted for a "vaginal birth after Caesarean," known as VBAC.

So when she had her fourth child this summer, she planned for another VBAC.

Late in her pregnancy, Canby said her obstetrician - and others in practice with him - told her that Washington County Hospital only would permit VBACs between 7 a.m. and 3 p.m., and that if her baby wasn't born within those hours, she would have to have another Caesarean.

"Three different doctors told me the same thing," Canby said.

The problem, she was told, was there might not be enough anesthesiologists on hand after hours to cover emergency surgery should complications arise.

Hospital officials said there never was a policy to restrict VBACs at the hospital, and they want to set the record straight.

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Because the hospital is a designated trauma center, it is required to have anesthesiologists in-house around the clock, "which meets the requirements for women to have VBACs," said Jody Bishop, administrative director of women's and children's services at the hospital.

She said that several months ago, the hospital's departments of anesthesiology and obstetrics reviewed VBAC procedures in light of the latest recommendations from the American College of Obstetricians and Gynecologists, and saw no need for change.

"Obviously, there was a miscommunication with someone," Bishop said. "Anesthesiologists are more available during the day, that's true." But she said the hospital had no restrictions on having the procedure.

"We analyzed the schedule, and decided it was OK," she said.

Staffing concerns

The new recommendations call for an obstetrician and anesthesiologist to be "immediately" available rather than "readily" available, said David H. Solberg, an obstetrician/gynecologist and chief of staff at Washington County Hospital.

"It may just be semantics," he said, but it could put physicians in a difficult situation.

Hospital staff is reduced after 7 p.m., Solberg said, and an anesthesiologist might not be "immediately" available if there are complications.

The problem is state and federal lawmakers have failed to reform medical malpractice statutes, he said.

"There's a natural resistance to put our necks on the line" when backup measures aren't available, Solberg said. One bad outcome, and "lawsuits can run into the millions, and a career is ended."

"Women who feel they're being restricted shouldn't be calling their doctors," Solberg said. "They should be calling their legislators."

Barry Wertheimer, chairman of the Department of Anesthesiology, said that when the procedure was reviewed, "we recognized that we didn't have unlimited staffing."

"What we said was from 7 p.m. to 7 a.m., we would restrict it and look at it closely" in terms of staffing, Wertheimer said. "It's a situational thing."

For example, if a woman in labor came in during those hours for a VBAC, and the hospital were to face serious injuries from an accident, an anesthesiologist might not be available if a problem arose, Wertheimer said.

"That's the point where you talk to the obstetrician," he said, and "the obstetrician, in consultation with us and the patient," would decide how to proceed. The issue is informed consent - making sure the mother knows the risks and that an anesthesiologist might not be available, he said.

Despite these concerns, Wertheimer said women still may have VBACs after hours.

"I can't tell you that anybody has been denied one," he said. "There have been very minimal complications from VBACs at Washington County Hospital."

Solberg said the hospital "did an excellent job of taking leadership" on the issue, calling together obstetricians, anesthesiologists and nursing staff to discuss it.

"We're now working through a protocol to improve safety," he said.

Solberg said the suggestion that VBACs would not be performed after hours was "absolutely false. I can tell you with complete sincerity that that's nowhere in the notes" from the review. Women can be restricted from having VBACs for medical reasons, he said, but the hospital doesn't have a policy restricting the procedure to regular hours.

After consulting with hospital officials, Canby's doctor told her she could have her VBAC - no matter what time she delivered, she said.

In the meantime, she contacted the Baltimore chapter of the International Cesarean Awareness Network.

"I found out I could refuse the (Caesarean) surgery," Canby said.

When Canby's daughter was born this summer, she had her VBAC - at 3 a.m.